|
CC:
|
|
|
Current Pain Level
/
|
Average Pain Level
/
|
|
Worst Pain Level
/
|
|
|
PMP Checked
|
|
|
Urine Toxicology Screen Performed
|
Specimen read by M.D.?
|
|
Valid Urine Toxicology Screen?
|
Drugs Present on Toxicology Screen
• • •
|
|
Last Urine Drug Screen (Date / / )
|
|
|
Plan
|
|
|
Therapies/Treatments Advised
• • •
|
Activity Instructions
• • •
|
|
Light Exercise/Activity Level Advised
|
|
|
Referrals Advised
• • •
|
|
|
Non-opioid Meds Comments
|
|
|
Opioids Prescribed
|
Violated Narcotic Agreement(Discharge)
|
|
Diagnosis subject to change
|
|
|
Short Acting Opioids
|
Short Acting Opioid SIG
|
|
Long acting opioids
|
Long Acting Opioid SIG
|
|
Face Time
• • •
|
Follow Up?
• • •
|
